2015_1023 IRRIGATION DOMESTIC FIRELINE X
The following farm must be completed for each assembly tested. A ;i�ned and ciated ariginal
must be submitted to the public water supplier for recordkeeping purposes
BACI{FLOW PRE�'ENTION ASSEMBLY T�ST AND�AI��ENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Ci�stomer)
MAILING ADDRESS: 253 Club Circle Dr Co�pAl1 TX 75019
CONTACT PERSOivrIPHONE:Denise 214-930-0933
LOCATION OF SERVICE: lOZ.1 C�1�,,,��
The backflow prevention assembly detailed belo��has been tested and mai��t�ined as required by
commission re�ulations and is certificd to be operating�;�ithin<icceptable��ai-_imeters.
'�"YPE QF ASSEI����i'
Reduced Presstu-e Principle Reducec� Pressure Priuciple-Detector
X Double Cl�eck Valve Double C11ecl:-Detector
PressureVacuumBreaker Spi1l=Resistant Pressure Vacuum Breaker
Manufacturer,�ryt�g �Iodel Numbe� �,pC�Q Size l„
Located At Se�ial Numbcr b(od l 1
Is the assembly installe in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assemblv Prc�sure Vacuw�i Breaker
Double Check Valve Assem�ly
1 st Check � Relief Valve Air Inlet Check Valve
nd Check
PQ°� Held at�Psid Hcld at�psid O�ened�it__ Oprned at Hcid at
Initial Test Closed Tight✓ Closed Tight ✓ psid psicl �Usi�{
Leaked Leaked Did not open Did not open Leaked
Repairs/
Materials
Used
Held nt psid Held at psid
Test After Ope�ied at Opened at Held at
Repair Closed Tight ' Closed Tight pS�d ps�� psid
Test gauge used: Make/Model Anollo 40-200-tk5u SN: 04.142867
Date Tested for Accuracy: 5/4/2015
Remarks:
The above is cer-tified to be tr�ie at the time of testing.
Firm Name Diamondbade Fire Proteetion Firnl Address PO Box 2507 Waxahachie TX 75168
Certificd Tester(pi-;�-t�oe Standridae Certitieci Tester(signature) �r
Finn Phone# (214) 444-3194 Cert.Test�,r No. BP0015823 Date 10/23/2015
�TEST RECORDS MUST BE KEPT FOR AT LEAST THREE 1'EARS
�'� USE ONLY MANUFACTURER'S REPLACEI��ENT PART'S
White-City Copy �'ello�v-Customer Copy Pink-Tester's Copy